Content
Fragments from the article: Vertesich K, Noebauer-Huhmann IM, Schreiner
M, Schneider E, Willegger M, Böhler C, Windhager R, Chiari C. The position of
the femoral fovea can indicate hip instability and highly correlates with
lesions of the ligamentum teres: an observational study (2025). The authors
discuss the diagnosis of pathology of the ligamentum capitis femoris (LCF) based
on radiological & MRI data. The text in Russian is available at the
following link: 2025VertesichK_ChiariC.
The
position of the femoral fovea can indicate hip instability and highly
correlates with lesions of the ligamentum teres: an observational study
Klemens Vertesich, Iris-Melanie Noebauer-Huhmann, Markus Schreiner,
Eleonora Schneider, Madeleine Willegger, Christoph Böhler, Reinhard Windhager
& Catharina Chiari
Abstract
Background
The aim of this study was to
assess the reliability of Delta angle (DA) as a parameter of microinstability
compared to established radiographic instability parameters. It was assessed
whether the morphology of the Ligamentum teres (LT) was affected by DA, established
instability parameters. Further, the correlation between clinical status and
microinstability parameters was assessed.
Methods
Data was retrospectively
analysed from a single centre database for hip preservations surgery. All
patients underwent a comprehensive and standardized radiographic and clinical
assessments. Sixty patients, with a mean age of 29.7 years (Standard Deviation [SD]
8.02), with 63 hips (40 right [63.5%] and 23 left [36.5%]) were included. Inter-observer reliability using the intraclass
correlation coefficient (ICC) method, Pearson Correlation Coefficient, and
further Analysis of Variance (ANOVA) and Multivariate Analysis of Variance
(MANOVA) with post hoc Bonferroni correction were performed.
Results
Inter-observer reliability
assessed by ICC showed excellent reliability for all radiographic parameters.
DA, as well as the Femoro-Epiphyseal Acetabular Roof (FEAR) index and (Gothic
Arch Angle) GAA, showed strong correlation with Lateral Centre Edge Angle
(LCEA) values. LT tears were highly linked to the presence of hip instability,
showing significant differences in each model when analysing DA as well as the
FEAR index and GAA (p < .001), MANOVA of microinstability parameters
combined with clinical tests showed significant correlation (p < .001) with
the Hyperextension-External Rotation (HEER) test. Other functional tests did
not show significant correlation.
Conclusion
The DA can be reliably
measured and can serve as a valuable supportive parameter in the assessment of
hip microinstability. Radiographic instability parameters showed significant
correlation with LT tears, suggesting they may function as useful additional
markers for this specific lesion. Additionally, a positive HEER test was
associated with the presence of microinstability parameters and may therefore
be included in the clinical evaluation of these patients.
Introduction
Deficient acetabular coverage of the femoral head during Developmental Dysplasia of the Hip (DDH) can result in mechanical overload and joint instability affecting the cartilage and/or acetabular labrum [1,2,3]. The Lateral Centre Edge Angle (LCEA) is a crucial parameter in classifying DDH or instability [4, 5]. Literature suggests that an LCEA threshold of 18°−20° or less may indicate the need for improved femoral coverage [6,7,8]. There is controversy regarding the treatment of patients with milder forms of dysplasia, where the LCEA ranges from 18°−25° [3, 9, 10]. Treatment options for these patients vary. Arthroscopic hip surgery addresses labral pathologies or CAM deformities. However, to address instability, frequently acetabular reorientation may be considered. Therefore, determining the appropriate treatment requires an assessment of hip instability parameters.
The Femoro-Epiphyseal Acetabular Roof (FEAR) index, a radiographic parameter for hip instability, is linked to the biomechanical properties of proximal femoral growth, based on the Hueter-Volkmann principle [11,12,13]. A positive angle is considered unstable. Wyatt et al. identified a threshold of 5° for recommending acetabular reorientation treatment [13]. Zimmerer et al. introduced the Gothic Arch Angle (GAA) [14, 15]. The GAA forms an angle between the apex of the gothic arch, the centre of rotation of the femoral head, and the central third of the femoral epiphyseal scar. An angle greater than 90° is considered unstable [14]. Excessive femoral antetorsion may lead to posterior bony impingement, causing anterior subluxation and instability. Addressing excessive femoral antetorsion through rotational osteotomy directly reduces anterior hip instability and improves patient outcomes [16].
The position of the femoral fovea also plays an important role in severe DDH [2, 3]. The Delta Angle (DA) is defined as the angle between the femoral fovea and the most medial part of the acetabular weight-bearing sourcil through the centre of rotation of the femoral head [17]. Beltran et al. described a method to assess the DA using magnetic resonance imaging (MRI) [18]. A negative DA, indicating fovea alta, may suggest hip instability or microinstability. However, the DA has not yet been established as a reliable instability parameter.
MR-arthrography of the hip with leg traction is beneficial in assessing Intra-articular structures [19,20,21,22]. Schmaranzer et al. demonstrated that this technique adequately assesses the ligamentum teres (LT), a structure that can be a potential source of intra-articular hip pain [23, 24]. Hip instability may affect the morphology of the LT, leading to partial or total tears [25]. Further, the presence of LT lesion directly affects outcome after hip arthroscopic surgery and needs to be detected [26].
This study aims to evaluated the reliability of the DA as a supportive
radiographic parameter for microinstability. It also aims to investigate
correlations of morphological changes of the LT, including tears, to
instability parameters. Additionally, it aims to identify clinical indicators
that may reflect underlying microinstability parameters.
Methods
This study was approved by the ethics committee of the Medical University of Vienna (Nr. 1829/2022) (Clinical trial number: not applicable). Due to the retrospective character of the study patient consent was waived by the ethics committee. In this observational study, data from patients with hip pain who presented at our outpatient clinic for hip preservation surgery from January 2020 to December 2023 were assessed. Patients underwent comprehensive and standardized radiographic and clinical assessments. If a patient experienced bilateral hip pain, both hips were investigated and included in the study. Clinical assessments included passive range of motion (ROM) evaluation, clinical testing such as assessment of Flexion-Adduction-Internal Rotation (FADIR), Flexion-Abduction-External Rotation (FABER), Hyperextension-External Rotation (HEER) and presence or absence of C-Sign. Patients with hip arthritis classified Tönnis grade 2 or worse, signs of congenital hip dislocation, and/or previous operations on the affected hip were excluded from the study. Sixty patients, with a mean age of 29.7 years (Standard Deviation [SD] 8.02), 36 female (60.0%) and 24 male (40.0%), with 63 hips (40 right [63.5%] and 23 left [36.5%]) were included in this study.
Radiographic assessments included an anteroposterior (a.p.) pelvis radiograph in the supine position, a Dunn view at 60° flexion, and MRI arthrography with axial leg traction and a torsional MRI profile of the lower extremities.
For MR arthrography, intraarticular injection was performed with 3 ml local anaesthetic (Ropinaest 2 mg/ml, B. Braun AG, Melsung, Germany) 5–20 ml of diluted MR contrast agent (Artriem (Gadoteric acid), Guerbet, Villepinte, France) under sonographic guidance by an anterior approach. MR was performed on a3.0T scanner (Siemens AG, Berlin, Germany) with flexible coils and a MR compatible traction device [20].
Traction was applied throughout the MR investigation. According to the original protocol 15 kg were used for patients who weighed < 60 kg, 18 kg were used for patients who weighed 60–80 kg and 23 kg were used for patients who weighed >80 kg [19, 20]. The following protocol was performed in every case: T2 STIR coronal; T1 TS FS inclined towards the femoral neck; T1 TSE FS paracoronal; T1 TSE FS parasagittal; Trufi 3D iso inclined towards the acetabulum with radial reconstruction; PD radial reconstruction along the femoral neck axis; rotation protocol of the lower extremities: T2 axial over both hips, knees and ankles.
Radiographic parameters, including LCEA, FEAR index, GAA, and DA, were assessed independently by two orthopaedic surgeons (K. V. and M. S., with 6 and 9 years of experience, respectively) who were blinded to the diagnosis and clinical presentation of the patients [13, 14, 17]. Patients were classified based on the LCEA value into three groups: Dysplastic (LCEA < 18°), Borderline Dysplastic (LCEA = 18°−25°), and Normal (LCEA >25°). Instability measurements were considered stable or unstable based on previously reported thresholds: the FEAR index was considered unstable at values of 5° or more; the GAA was considered unstable at values of 90° or more; and the DA was considered unstable at values of 0° or less (negative values) (Fig. 1A, B).
 |
| Fig. 1 A, B shows an example of measuring the Delta Angle (DA) in two borderline dysplastic hips. Figure 1A shows an overlapping of femoral fovea and acetabular weight bearing sourcil, indicated by a negative DA value. Figure 1B shows a positive DA value and no overlapping of femoral fovea and acetabular weight bearing sourcil. The schematic images in the bottom of A and B display the atomical constitution of the joint with the Ligamentum Teres (LT) impinging in the articular surface of the hip joint when the DA is negative |
MRI assessments were performed by a radiologist (I. N-H., 27 years of experience) and included evaluations of acetabular version and femoral torsion, as well as classification of LT morphology according to the modified classification for MR arthrography of the hip with axial leg traction: Type 0 – intact/no altered signal; Type I - hypertrophy/intermediate signal, LT dimensions exceeding femoral fovea width; Type II – partial thickness/fiber discontinuity; Type III – complete/full-thickness tear [21, 22, 27].
Acetabular version was measured between a line through the anterior and posterior rim of the acetabulum and a perpendicular line through both posterior corners of the acetabula to neutralize for rotation [28]. Femoral torsion was assessed using the method previously described by Murphy et al. [29]. The McKibbin index was used to assess the effect of a combined value of acetabular version and femoral torsion. It is defined as the sum of femoral torsion and acetabular version [16, 30, 31].
Data distribution was evaluated using the Kolmogorov-Smirnov method.
Inter-observer and intra-observer reliability was assessed using the Intraclass
Correlation Coefficient (ICC) method [32]. Correlations were assessed by using
Pearson Correlation Coefficient (PCC). PCC was classified as very weak <
0.1, weak 0.1–0.4, 0,4–0.6 moderate, 0.6–0.8 strong and >0.8 very strong.
Differences in the presence of altered LT signals were assessed using Analysis
of Variance (ANOVA) and Multivariate Analysis of Variance (MANOVA) with post
hoc Bonferroni correction. MANOVA was performed for each individual clinical
test including LCEA, FEAR index, GAA and DA as dependent variables. P-values
less than 0.05 were considered statistically significant. Statistical analyses
were performed using SPSS v29 (IBM Co., Armonk, NY, USA) and GraphPad Prism 10
(GraphPad Software Inc., Boston, MA, USA).
Results
Reliability of radiographic parameters
Excellent inter-observer reliability was observed for all radiographic
parameters of instability: the LCEA showed an ICC of 0.947 (95% CI:
0.912–0.968; p <.001), the FEAR index an ICC of 0.907 (95% CI: 0.846–0.944;
p <.001), the GAA an ICC of 0.937 (95% CI: 0.896–0.962; p <.001), and the
DA an ICC of 0.935 (95% CI: 0.892–0.960; p <.001) (Table 1).
 |
| Table 1 Descriptive statistics on radiographic measurements displays means and standard deviation for mean value between readers and separated by different readers 1 and 2 (V. K., S.M.) including agreement of inter-observer reliability assessed by intraclass correlation coefficient (ICC). (LCEA – Lateral centre edge Angle; FEAR index – Femoro-Epiphyseal acetabular roof index; GAA – Gothic arch Angle; DA – Delta Angle; ICC - intraclass correlation coefficient) |
Assessment of intra-observer reliability similarly demonstrated
excellent agreement. The LCEA had an ICC of 0.932 (95% CI: 0.890–0.958;
p <.001), the FEAR index an ICC of 0.965 (95% CI: 0.943–0.979; p <.001),
the GAA an ICC of 0.960 (95% CI: 0.943–0.975; p <.001), and the DA an ICC of
0.936 (95% CI: 0.896–0.960; p <.001).
Correlation of instability and DA compared to established instability
parameters
The LCEA showed a strong correlation (PCC of − 0.637 (p <.001)) with
the FEAR index, a strong correlation (PCC of − 0.640 (p <.001)) with the GAA
and a strong correlation (PCC of 0.689 (p <.001)) with the DA. (Fig. 2A-C)
 |
| Fig. 2 A-C Scatter plotting and Pearson Correlation Coefficient (PCC) of Lateral Centre Edge Angle (LCEA) by Femoro-Epiphyseal Acetabular Roof (FEAR) index (A), by Gothic Arch Angle (GAA) (B) and by Delta Angle (DA) (C) show strong correlation of measurements |
Correlation of DA with established instability parameters showed a very
strong correlation with a PCC of − 0.811 (p <.001) for FEAR index and a
strong correlation with a PCC of − 0.811 (p <.001) for GAA. (Fig. 3A, B)
 |
| Fig. 3 A, B Scatter plotting and Pearson Correlation Coefficient (PCC) of Delta Angle (DA) by Femoro-Epiphyseal Acetabular Roof (FEAR) index (A) and by Gothic Arch Angle (GAA) show very strong correlation of measurements |
After categorizing the patient groups according to the LCEA, 5 hips
(7.9%) were considered dysplastic, 35 hips (55.6%) were considered borderline
dysplastic and 23 hips (36.5%) were considered as normal coverage. FEAR index
considered 6 hips (9.5%) as unstable, GAA and DA both considered 10 hips
(15.9%). DA and GAA showed a congruence of 100%, DA and FEAR index a congruence
of 93.7% of cases, respectively. Further analysis of 35 hips (36.5%) considered
borderline dysplastic showed that 6 hips (17.1% of borderline dysplasia) had
signs of instability and the other 29 hips (82.9%) were considered stable.
Morphology of LT in presence of instability
LT was intact (Type 0) in 21 hips (33.3%), hypertrophic (Type I) in 14
hips (33.3%), partially torn (Type II) in 18 hips (22.2%) and torn (Type III)
in 10 hips (15.9%) (Fig. 4A-D). Comparing LCEA values based on the presence of
LT conditions, ANOVA showed significance for full-thickness tears of the LT compared
(p =.003). When further assessing each value of FEAR index, GAA and DA ANOVA
detected highly significant differences when assessing for full-thickness LT
tears (Type III) (p <.001). Partial tears (Type II) or LT hypertrophy (Type
I) showed no significance when comparing mean differences (Fig. 5A-D).
 |
| Fig. 4 A-D Examples of LT morphology in MR arthrography with axial leg traction classified in intact LT (a), Type I- LT hypertrophy (b), Type II – partial LT tear and Type III- LT full-thickness tear |
 |
| Fig. 5 A-D Boxplot overview of Ligamentum Teres (LT) morphology and different measurements. Figure 5 A Displays LT morphology by mean Lateral Centre Edge Angle (LCEA) significant differences when comparing LT tears to intact and hypertrophic LT but no significance when comparing to partial tears. Figure 5 B-D Showing LT morphology by means of Femoro-Epiphyseal Acetabular Roof (FEAR) index, Gothic Arch Angle (GAA) and Delta Angle (DA) showing highly significant differences when comparing LT tear to other LT conditions. (n.s. – not significant; * - p <.05; *** - p <.001) |
When analysing femoral torsion and McKibbin index, both showed no
significant differences between the groups when assessing for LT changes.
Influence of clinical parameters on micoinstability parameters
Functional clinical tests, including FADIR, FABER, HEER, and C-sign,
were analysed using MANOVA alongside LCEA, FEAR index, GAA, and DA. This
analysis demonstrated that a positive HEER test was associated significantly
with microinstability parameters. Further, the single-factor analyses showed
significant differences in instability parameters in association with the HEER
test. These results are highlighted in Table 2.
 |
| Table 2 Single factor analysis of Hyperextension-External rotation (HEER) test showing significantly different values for lateral centre edge angle (LCEA), Femoro-Epiphyseal acetabular roof (FEAR) index, Gothic arch angle (GAA) and delta angle (DA) |
Discussion
Instability of the hip is a significant issue in hip preservation surgery, influenced by biomechanical properties during skeletal development [3]. Detecting instability is crucial for determining the best treatment options, especially in cases with borderline dysplasia [33]. Using the position of the femoral fovea, assessed by the DA, this study shows that additional information on potential instability or microinstability can be gathered. Further, lesions of the LT are highly correlated with the DA and established instability measurements [25].
Established instability parameters as well as the DA, showed excellent inter-observer reliability [32]. These findings are comparable to several other studies analysing the LCEA, FEAR index, and GAA. Wyatt et al., who first described the FEAR index, demonstrated almost perfect reliability for this parameter [13]. Our results achieved excellent reliability.
Detecting signs of instability is crucial for determining the correct treatment [34, 35]. Microinstability in borderline dysplastic hips represents a critical entity. In this study we found 19.1% of hips with borderline dysplastic LCEA to show signs of instability. Zimmerer et al. assessed solely hips with borderline dysplasia, where 39% had signs of instability [14]. In the presence of instability, outcomes after hip arthroscopy remain inferior [3, 36]. Therefore, the assessment of parameters indicative of hip microinstability should be implemented in the routine workup of painful young adult hips and incorporated into the decision-making process for the optimal treatment. The assessment of these parameters used in this study showed equivalent correlation with LCEA compared to previous studies [13, 14]. Further, our data suggest that assessing the DA has a similar correlation with LCEA compared to FEAR index and GAA. Based on our data, we believe that the position of the femoral fovea, assessed by the DA, represents an additional supportive parameter in detecting hip instability.
Various theories consider the LT as potential source of intra-articular pain. Cadaveric studies and basic research showed a potential role as secondary stabilizer, leading to alterations in dysplastic or unstable hips [37]. Others suggest that free nerve endings in the LT have an effect on pain quality, especially when the structure is torn [23]. Clinically, lesions of the LT may affect results of hip arthroscopy, which indicate that the state of the LT should be considered in the decision-making process for the optimal treatment [24, 26]. However, the causality between LT lesions and hip instability remains unclear. Longitudinal studies are needed to investigate whether LT tears result from or contribute to hip instability. Nevertheless, our data show a strong correlation between the DA, FEAR index, and GAA and complete tears of the LT. However, other radiological presentations of the LT do not significantly correlate with instability parameters. Based on these findings these parameters can serve as an supportive markers for complete LT tears (Type III).
Hoppe et al. evaluated various hip instability tests and their diagnostic accuracy, highlighting the high sensitivity and specificity of the HEER test [38]. Both MANOVA and single-factor analyses demonstrated a significant relationship between the HEER test and all microinstability parameters in this study. Conversely, the clinically relevant and traditionally common C-sign, did not show a significant correlation with microinstability parameters. The incorporation of provocation test in the routine clinical evaluation may be beneficial for detecting instability symptoms.
Several limitations have to be mentioned. The retrospective study design
is susceptible to selection biases. Further hip instability in this study was
defined by radiographic parameters, which is important especially in planning
of a potential surgical procedure. This study aimed to find an additional
radiographic tool for investigating instability. Based on the retrospective
character and the lack of control group an evaluation of predictive accuracy
was not performed. This represents a notably limitation and suggests that this
finding are considered as exploratory. The instability parameters used in this
study remain static parameters. The effect of joint motion on the hip with
morphological changes including pelvic tilt, pelvic rotation, acetabular
version or femoral version were not assessed. To evaluate these effects further
research including 3D motion modelling would be necessary. Further, three
patients had both hips included in the study, which may introduce a slight bias
due to the potential similarity in their hip morphologies. A potential bias in
pre-test probability has to be noted, as only individuals presenting to a hip
preservation centre due to pain were included.
Conclusion
The position of the femoral fovea plays a supportive role in patients
with hip pain. The DA strongly correlates with the FEAR index and GAA. This
study suggests the use of DA as an additional supportive parameter when
assessing signs of microinstability of the hip. However, further studies with
inclusion of larger subgroups are needed to confirm these findings and evaluate
diagnostic accuracy. Microinstability parameters showed significant correlation
with LT tears, indicating they may be used as radiographic helpful parameters
to detect this particular type of lesion. Functional instability testing using
the HEER test correlates with the presence of microinstability parameters and
may be valuable in assessing patients with suspected hip microinstability.
Data availability
The data supporting the findings of this study are presented within the
manuscript. The datasets used and/or analysed during the current study are
available from the corresponding author upon reasonable request, subject to
institutional and ethical guidelines.
Abbreviations
a.p.: anteroposterior
ANOVA: Analysis of Variance
DA: Delta Angle
DDH: Developmental Dysplasia of the Hip
FABER: Flexion-Abduction-External Rotation
FADIR: Flexion-Adduction-Internal Rotation
FEAR: Femoro-Epiphyseal Acetabular Roof
GAA: Gothic Arch Angle
HEER: Hyperextension-External Rotation
ICC: Intraclass Correlation Coefficient
LCEA: Lateral Center Edge Angle
MANOVA: Multivariate Analysis of Variance
MRI: Magnetic resonance imaging
PCC: Pearson Correlation Coefficient
ROM: Range of motion
SD: Standard Deviation
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Vertesich K, Noebauer-Huhmann IM, Schreiner M, Schneider E, Willegger M, Böhler C, Windhager R, Chiari C. The position of the femoral fovea can indicate hip instability and highly correlates with lesions of the ligamentum teres: an observational study. BMC Musculoskeletal Disorders. 2025;26(1)1028. https://doi.org/10.1186/s12891-025-09267-7 link.springer.com
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Contributions
K.V., M.W., C.B., R.W. and C.C.
contributed to study design and methodology. Data acquisition and data analysis
was performed by K.V., I.N-H., M.S., E.S., M.W. and C.C. The manuscript was
written by K.V. and all authors commented on previous versions of the
manuscript. All authors read and approved the final manuscript.
Ethics approval and consent to
participate
This study was approved by the ethics committee of the Medical University of Vienna (Nr. 1829/2022). This study was performed at the Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Waehringer Guertel 18–20, 1090 Vienna, Austria. The study has been performed according in compliance to the Helsinki Declaration. Patient consent was waived due to retrospective study design.
Department of Orthopedics and Trauma Surgery, Medical University of
Vienna, Waehringer Guertel 18-20, Vienna, 1090, Austria
Klemens
Vertesich, Markus Schreiner, Eleonora Schneider, Madeleine
Willegger, Christoph Böhler, Reinhard
Windhager & Catharina Chiari
reinhard.windhager @ meduniwien.ac.at
Department of Biomedical
Imaging and Image Guided Therapy, Medical University of Vienna, Waehringer
Guertel 18-20, Vienna, 1090, Austria
Iris-Melanie Noebauer-Huhmann
Department of Pediatric
Orthopaedics and Foot and Ankle Surgery, Orthopedic Hospital Speising,
Speisinger Straße 109, Vienna, 1130, Austria
Catharina Chiari
ligamentum capitis femoris, ligamentum teres, ligament of head of femur, damage, diagnostics, radiology, pathology
NB! Fair practice / use: copied for the purposes of criticism, review, comment, research and private study in accordance with Copyright Laws of the US: 17 U.S.C. §107; Copyright Law of the EU: Dir. 2001/29/EC, art.5/3a,d; Copyright Law of the RU: ГК РФ ст.1274/1.1-2,7
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